LIFESTYLE INTERVENTIONS FOR NON-ALCOHOLIC FATTY LIVER DISEASE - Kirsten Coppell, Public Health Physician - New Zealand Society of ...
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LIFESTYLE INTERVENTIONS FOR
NON-ALCOHOLIC FATTY LIVER
DISEASE
Kirsten Coppell, Public Health Physician
Senior Research Fellow, Department of Medicine, University of Otago; Training Programme Supervisor, NZCPHM
Principles of Healthy Eating
In 9 words…..
• Eat less
• Move more
• Eat mostly fruits and vegetables
For additional clarification – a 5 word modifier……
• Go easy on junk foods
Nestle, Marion (2006). What to Eat. New York: North Point Press (Farrar, Straus and Giroux). ISBN 978-0-86547-738-4.
HOW?
How much does weight loss surgery cost?
Weight Loss Surgery Fees
Initial Consultation $280
Gastric Banding Surgery $18,500
Gastric Sleeve Surgery $20,750
Gastric Bypass Surgery $23,500
Additional Fees
The Optifast pre-surgery meal replacement diet must be purchased separately from your local pharmacy.
Other additional costs may include staying extra nights in hospital, extra theatre time, blood transfusion and/or x-rays.
PLEASE NOTE: 99% of patients do not incur additional costs.
Based on these costs………
To provide BS for 192,000 210,000 with BMI ≥40kg/m2 @ $20,000 per
operation =
$3,840,000,000 $4,200,000,000
$74.46M PHARMAC 2017 Year in Review
570,000 PHARMAC 2016 Year in Review
The prevalence of overweight and obesity in
NZ adults by age group, 2016/17.
100
Overweight Obesity
90
80
70
Proportion (%)
60 38.4 39.3 27.0
32.4 37.2
50 31.1
40 24.0
14.7
30 12.3
20
10
0
0-14 15-17 18-24 25-34 35-44 45-54 55-64 65-74 75+
Age Groups
Ministry of Health. Annual Update of Key Results 2016/17: New Zealand Health Survey. Ministry of Health; 2017.
Diabetes and prediabetes age-specific rates for NZ
men and women aged 15 years and over.
Prediabetes - men Diabetes - men Prediabetes - women Diabetes -women
60
50
40
Prevalence (%)
30
20
10
0
15-24 25-34 35-44 45-54 55-64 65-74 75+
Coppell K et al. NZ Med J, 2013 Age groups (years)Proportion of women giving birth, by body mass index
(BMI) category at first registration with their primary
maternity care provider, 2008-2015.
Ministry of Health. Report on Maternity 2015. Wellington: Ministry of Health; 2017.Non-alcoholic fatty liver disease (NAFLD) in NZ
???The elevated ALT and GGT rates by body mass index category and glucose
metabolism disorders for men and women aged 15+ years
Men (n=1,327) Women (n=1,708)
ALT % (95% CI) GGT % (95% CI) ALT % (95% CI) GGT % (95% CI)
Body mass index
category (kg/m2)
Normal 7.7 (3.6-11.8) 7.1 (3.4-10.9) 4.9 (2.6-7.2) 6.6 (4.0-9.2)
Overweight 15.8 (11.0-20.6) 12.0 (8.4-15.6) 10.5 (6.5-14.6) 15.1 (10.8-19.4)
Obese 28.5 (21.7-35.4) 20.9 (15.7-26.1) 16.0 (11.4-20.5) 23.3 (18.3-28.4)
Glucose metabolism
disorder
Normal 16.0 (12.0-20.0) 10.1 (7.4-12.9) 7.1 (5.0-9.2) 10.0 (7.6-12.5)
Prediabetes 17.3 (11.5-23.1) 16.3 (11.3-21.3) 15.7 (10.6-20.9) 20.9 (15.6-26.2)
Diabetes 23.1 (12.8-33.4) 26.2 (16.7-35.6) 15.2 (7.3-23.0) 36.5 (26.0-47.0)
Coppell KJ, Miller JC, Gray AR, Schultz M, et al. Obesity Science and Practice, 2015.ANZLT Registry Report 2017
Clinical Guidelines for Weight Management in New Zealand Adults Ministry of Health, Clinical Trials Research Unit. 2009. Clinical Guidelines for Weight Management in New Zealand Adults. Wellington: Ministry of Health.
Number
2000
3000
4000
7000
0
6000
1000
5000
8000
1859
1908
1914
1918
1925
1928
1932
1935
1938
1942
1945
1948
1951
1954
1957
1960
Year 1963
1966
1969
1972
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
2008
Annual number of publications on weight loss, 1859-2018
2011
2014
2017List of ‘fad’ diets
• The 4-Hour Body • Macrobiotics • Whole30 diet
• 5:2 diet • Master Cleanse • High carb/low fat diets
• Dr. Dean Ornish: Eat More, Weigh
• Alkaline diet • [Mediterranean diet] Less
• The Good Carbohydrate Revolution
• Baby Food Diet] • Morning banana diet
• the Pritikin Principle
• Blood type diet • Paleolithic diet
• Food combining
• Cabbage soup diet • Pritikin Diet • Fit for Life
• Detox diet • Scarsdale medical diet • Suzanne Somers’ Somersizing
• Dukan Diet Fruitarianism • South Beach Diet • Liquid diets
• Cambridge Diet
• Gluten fee diet, while essential for • Superfood diet
people with coeliac disease or gluten • Slim-Fast
sensitivity, has also been a fad. • Veganism
• Diet pills, supplements and herbal
• Grapefruit diet • Ketogenic diet remedies
• Dexatrim Natural
• Israeli Army diet • Low-carbohydrate diets • HCG diet
• Atkins diet
• Juice fasting • Hydroxycut
• Sugar Busters
• Metabolife 356
• KE diet • Zone diet
https://en.wikipedia.org/wiki/Fad_diet#cite_note-Nestle2006-11Diabetes Diabetes Prevention Prevention Program Study (DPP) (DPS)
Finnish Diabetes Prevention Study (DPS) Intensive lifestyle intervention reduced incidence of diabetes by 58% compared with standard lifestyle recommendations over an average follow-up 3.2 years Lifestyle goals • to achieve BMI
Diabetes Prevention Program (DPP)
Intensive lifestyle intervention reduced incidence of diabetes by 58%,
and metformin by 31% compared with standard lifestyle
recommendations over an average follow-up 2.8 years
Lifestyle goals
• to achieve and maintain weight reduction of at least 7% through
healthy low calorie, low-fat diet
• to engage in physical activity of moderate intensity, such as brisk
walking, for at least 150 minutes per weekEffect of weight loss on NASH study
Intensive weight loss intervention based on strategies used successfully
in the DPP, Look AHEAD study and behavioural trials. After 48 weeks
intervention group lost an average of 9.3% of their body weight vs 0.2%
in the control group, and their NASH activity score improved
significantly from 4.4 to 2.0 compared with 4.9 to 3.5 in the control
group (p=0.05).
Lifestyle goals
• 7-10% weight loss within 6 months then maintain through low calorie
and low fat
• to engage in physical activity of moderate intensity, such as brisk
walking, for at least 150 minutes per week increasing to 200 minutes
per week by 6 months
Promrat K, Kleiner DE, Niemeier HM, et al. Hepatology. 2010;51(1):121-9. doi: 10.1002/hep.23276.Diabetes risk in the DPP by percent weight loss
achieved at 6 months (mean follow-up 2.7 years)
Adjusted Hazard Ratio
51%
Maruther et al. J Gen Intern Med 2013; 28: 1629-36Diabetes risk in the DPP by percent weight loss achieved
at 6 months (mean follow-up 2.7 years)
13% 6%
Maruther et al. J Gen Intern Med 2013; 28: 1629-36How was the lifestyle advice delivered in the DPP?
• 16-lesson curriculum covering diet, exercise and behavior
modification
• curriculum taught by case managers on a one-to-one basis
during first 24 weeks
• curriculum followed by monthly individual sessions and
group sessions designed to reinforce behaviour changes
• sessions flexible, culturally sensitive and individualised
• case manger
• cost to deliver the intervention in the first year was
$US1,399 per participantHow was the lifestyle advice delivered in the DPS?
• Individually designed programme taking into account needs,
interests, educational level and person who is ‘primarily in
charge of preparing food at home’
• Baseline 3-day food record to form basis of dietary advice
• Advise CHO – 50%;
saturated fat 30kg/m2, then 6-12
week VLCD and group meetings at 1-2 weekly intervalsSupplement—Nutrition
Education in Training Medical
and Other Health Care
Professionals
“Nutrition and physical activity are key
risk factors for a host of today’s most
prevalent and costly chronic conditions,
such as obesity and diabetes; yet,
health care providers are not
adequately trained to educate patients
on the components of a healthy
lifestyle.”
Levy MD, Loy L, Zatz LY. Policy approach to nutrition and physical activity education in health care
professional training. Am J Clin Nutr 2014; 99(suppl):1194S-201S.HOW?
Prediabetes intervention package (PIP)
in primary care studyPrediabetes intervention package (PIP) in primary care study To examine the effect and implementation of a multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice on weight and glycated haemoglobin in patients with prediabetes at 6 months.
Approach to nutritional advice
Lipids, Blood
pressure, Glycaemic
control
Cultural
background Lifestyle
Family &
Employment BudgetLifestyle questions Weight History
• Special Diet or food allergies (tick if • Has your weight tended to go up and
applicable): Vegetarian, Vegan, down?
Pescatarian (vegetarian + fish), Nut • How long have you been your current
free, Dairy free, Gluten free , Etc weight?
• Physical activity – frequency and type Clinical Notes – suggested optional
questions
• Please indicate who you live with?
• What was a weight that you felt
• Who mostly buys food in your house? comfortable at?
• Who mostly cooks food in your house? • Where do you hope to be in 6 Months?
• Is your budget for food limited? On a • Where do you hope to be in 2 Years?
scale of 1 - 10, how ready are you to Diet Assessment
make food changes (1 - not ready at
all; 10 – really motivated)? • Starting The Conversation (STC): Diet
• Detailed Dietary Assessment GuideGoals - examples
• Less margarine on toast/bread. Just a scraping. Half the
amount of butter in mashed potatoes
• Plan meals in advance cooking extra meals in days off
• To watch how much fruit is used in smoothies
• Will swap takeaway fast foods once per week i.e. stuffed
fried chicken dish to either small chicken chow mein or
turkish wrap with hummus
• change from coke to diet sodas - add a glass of water a day
in the morning and decrease from 3 to 2 teaspoons of miloOne participant’s story
• 61 year old Pacific woman. Lived by herself. No local family
support.
• Both mum and dad history of Type 2 DM.
• Did no exercise.
• Weight had been constant for 18 months.
• Food budget was $20 per week.
• Attended churches for food.
• Used Food banks.Baseline Measures • HbA1c: 46 mmol/mol • Weight: 125.7 kg • Waist : 134 cm • BP: 136/84 mmHg • BMI: 47.6 kg/m2
Dietary Information Main diet intake: • Bag Powdered milk • Bag Rolled oats • Potatoes • Noodles • Occasionally $5.00 pork bones • $1 bread • Limited meat • Limited vegetables • $2.00 bag biscuits
3-month follow up
Baseline 3 month
HbA1c 46 mmol/mol 44 mmol/mol
Waist 134 cm 112 cm (22 cm loss)
Weight 125.7 kg 124.4 kg (1.3 kg loss)
Blood pressure 136/84 mmHg 132/82 mmHgAnother participant’s story
• 53 year old Maori man with partner living in another town.
• Unemployed.
• Current smoker.
• Ischemic heart disease, COPD.
• Prediabetes diagnosed 2014 (HbA1c 42 mmol/mol)
• CVRA >20%
• Medications - Flixotide, Duolin, Aspirin, Dilitazan
Hydrochloride, Atorvostatin, Nitrolingual spray.Baseline Appointment
• HbA1c: XX mmol/mol Nutritional goals
• Weight: 86.5 kg 1. Increase fruit to 2 servings daily.
• Waist circumference: 98 cm 2. Increase veges to 4 servings
• BP: 159/104 mmHg daily.
• Weight loss goal 8.65kg 3. Reduce usual sugar in coffee by
half to 2 tsp each cup.
• Financial Stress.
• Non compliant with meds - GP
appt.2-3 week Appointment – attended with partner
• Weight increased by 2.5 kg Revised nutritional goals
• BP: 159/110 mmHg • New goal - source apples, bananas
and mandarins. Eat 2x daily.
• Eating veges 3x daily
• Discussed Kia Ora community
• Reduced sugar in coffee to 2 tsp education programme.
per cup
• Appt made GP - WINZ and Kiwisaver.
• Decreased salt intake & eating fish • Referred to Social Worker.
2x week
• Refused smoking cessation support.6 week Appointment
• Achieved previous nutrition goals Revised nutritional goals
• Weight decreased to 83.5 kg • Plan and prepare healthy snack
• Waist circumference decreased to options.
94 cm [4cm less than at baseline] • Eat chips 1x week.
• BP 140/101 mmHg • Referred to Kia Ora programme.
• Waiting to hear back from Social
Worker.Month Weight BMI HbA1c Goal 1 Goal 2 Goal 3
0 79.7 29.45 44 healthy takeaways, ie healthier sweet increase vege portions
subway or turkish options ie smoothie, and decrease plate
fruit, size
1 77.9
3 73.5 27.16 41
6 70.3 25.98 40
Had takeaway last week, had turkish. Denied self ice cream at the movies, is being minndful when openns fridge not
to pick, having smaller meat portions.
3rd PIPI visit - pt done so well, great wt loss\bp 158/80\wt 73.5\wc 92.5Has passed wt goal which was 76kgwc originally
100cm.
…..been very focussed on her weight and food goals and is a bit concerned as has been staying with her daughter to
help out and they eat higher fat and CHO than she likes. I can see that she prefers to eat her healthy options with the
occasional sweet treat. Pt has been grateful for this opportunity.Month Weight BMI HbA1c Goal 1 Goal 2 Goal 3
0 82.7 27.63 41 To increase non-starchy To reduce amount of Stop having desserts
vegetables to 7+ serves crackers per week to 2-3
and fill half the meal times, alternate cheese
plate with vegetables with cottage cheese
1 81.1 41
3 78.4 26.2 43
6 77.0 25.73 40
Is achieving all goals and would like to continue with these as he feels they are working really well. He found the first
2/7 difficult but felt that it was a habit he could break. He has lost 1.6 kg. Green rx referral faxed.
Doing well lost more weight, happy with goal, achieving these nicely.looking forward to knowing what effect this may
have made on his bloods
Has achieved all goals and will continue to do this. Found the green rx modules of benefit particularly the label
reading, enjoyed the modules! Has lost nearly 6kg. His weight goal was 78 so achieved this. Feels happy at the weight
he is now and would like to maintain this rather than lose more. Keen to follow up in 2-3mths for weight and nutrition
r/v. Recall set.Other personal and ‘life’ considerations
• Diet modification challenges faced by
marginalized and nonmarginalized adults Self-
with type 2 diabetes: A systematic review discipline
and qualitative meta-synthesis.
[Vanstone M, Rewegan A, Brundisini F, et al.
Chronic Illn. 2017;13(3):217-235.]
Knowledge Family and
• Five inter-connected barriers to and social
diet modification that are
magnified by social information Dietary support
marginalization.
• Abel S, Whitehead LC, Coppell KJ.
change
Making dietary changes following a
diagnosis of prediabetes: a qualitative Social
exploration of barriers and faciliators.
Diabet Med. 2018 Aug 9. doi: Emotions significance
10.1111/dme.13796. [Epub ahead of print] of food“Can look at a habit now
and decide if I want to keep
it or change it.”Collaborators Trish Freer, Health Hawke’s Bay Leigh Perreault, University of Colarado Kiri Sharp, University of Otago David Tipene-Leach, Eastern Institute of Technology Joanna Norton, University of Otago Tony Merriman, University of Otago Sally Abel, Kaupapa Limited Jeremy Krebs, University of Otago Terry Spedding, Health Hawke’s Bay Angeline Tangiora, Health Hawke’s Bay Rachael Engelbrecht, Tamatea Medical Centre Diane Stride, Diane Stride Dietitian Postgrad Students Lillian Ward, Health Hawkes’ Bay Deborah Connor, University of Otago Andrew Gray, University of Otago Lisa Whitehead, Edith Cowan University, Australia Research Assistant Trudy Sullivan, University of Otago Courtney Mizen, Edith Cowan University, Australia
Acknowledgements
Practice nurses from Greendale Family Health Centre
The Doctors Napier
Te Mata Peak Practice
Clive Medical Centre
The Hastings Health Centre
Hauora Heretaunga
Medical and Injury Centre
Maraenui Medical Centre
Tamatea Medical Centre
Chris Peterson & Helen Morris Faye Milner & Janet Hill
Diabetes New Zealand Healthy Food Guide
Zoe McCulloch
Southern Community Laboratories
Lenore Armstrong & Leslie TurnerThe pre-diabetes tidal
wave - harbinger of doom
or symptom of an
overdiagnosis epidemic?
NIKKI MACDONALD
April 15 2017
…..diagnosed with pre-diabetes about three years ago, after having an
Hba1c test’…never considered herself at risk of diabetes….”I thought I was
far too active for that.“ She knew diabetics, who needed insulin injections,
and her fear of needles was motivation enough to change. She was
referred to the Otago University pilot Pre-diabetes Intervention
Programme in Primary Care (Pipi), trialling targeted diet advice through GP
practice nurses…….She now eats fewer strawberries and greener
fruit…swapped white rice for couscous or mixed rice, eats more fish and
only fibre-dense bread. When family visit, it's a big feed, but a healthy one.
"They know what I'm doing and that I won't allow them to have rubbish. Napier 70-year-old Gayle Peters was told she
Not here." She's lost some weight, and has not progressed to full diabetes. was pre-diabetic about three years ago. With
Overall, she found the experience "very useful“…….As you do it more and it targeted diet advice, she reduced her sugar and
carbohydrate intake and has not progressed to
starts becoming more second nature, it's just changing your style of living."
diabetes. PHOTO: SUPPLIED
http://www.stuff.co.nz/national/health/90768856/The-pre-diabetes-tidal-wave-harbinger-of-doom-or-symptom-of-an-overdiagnosis-epidemicPrevalence of obesity (BMI ≥30 kg/m2) among
New Zealand men and women aged 15+ years
Women Men
40
35
30
Proportion (%)
25
20
15
10
5
0
Year
Ministry of Health. 2013. New Zealand Health Survey: Annual update of key findings 2012/13. Wellington: Ministry of Health.
Ministry of Health. 2017. New Zealand Health Survey. Annual Data Explorer. minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-
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